turn the very fearlessness that may facilitate self-injury against it-
self. Though not a routinely useful part of crisis interevention, this
tactic may have promise for some patients, in that it redirects the re-
solve of the suicidal person on to fighting against evil on behalf of
others, which in turn may alleviate low belongingness and perceived
burdensomeness.
As with risk assessment, the theory of suicide developed in this
214 ● WHY PEOPLE DIE BY SUICIDE
book guides clinical activity in the realm of crisis intervention.
Short-term interventions that target and take the edge off of per-
ceived burdensomeness and feelings of failed belongingness are likely
to contribute to crisis resolution.
Treatment and Prevention
William James wrote, “Be not afraid of life! Believe that life is worth
living and your belief will help create the fact.”11 As was so often the
case, James was ahead of his time. My colleagues and I have docu-
mented that psychotherapy that is focused on amending negative
thoughts about self, others, and the future (cognitive therapy) is the
leading treatment for suicidal behavior.12 We also developed and de-
scribed a particular form of cognitive therapy for suicidal behavior.
Two aspects of this therapy deserve emphasis here. The first is a
technique for restructuring negative thoughts to which we gave the
acronym ICARE. Each of the letters in the acronym stands for a
step in the process of altering negative thoughts. “I” stands for iden-
tification of a particular negative thought. In context of my model
of suicidal behavior, thoughts related to burdensomeness and low
belongingness should be prioritized.
“C” stands for connection of the particular thought to general
categories of cognitive distortion. There are numerous kinds of cog-
nitive distortion. Some examples include all-or-nothing thinking,
catastrophizing, disqualifying the positive, and overgeneralization.
All-or-nothing thinking involves viewing a situation inflexibly, with
only two extreme categories (“if everyone doesn’t love me, then I’m
unlovable”). Catastrophizing is predicting the future in a very nega-
tive way, without consideration of more likely outcomes (“I’ll be so
upset that I will be unable to function”). Disqualifying the positive
means not counting positive qualities or experiences as real (“My
success was just dumb luck”). Overgeneralization involves sweeping
negative conclusions that go well beyond the data provided by a
Assessment, Intervention, Treatment, and Prevention ● 215
given situation (“I felt uncomfortable at a party, therefore I am so-
cially defective”).
The first two steps, identifying the thought and connecting it to a
larger type of cognitive distortion, set up the third and fourth steps.
“A” is for assessment of the particular thought, in light of tried and
true cognitive therapy techniques. These techniques essentially in-
volve questions like these: What is the objective evidence for the
thought? Against the thought? How likely is it? Are there alternative
explanations? Will it matter in a year?
“R” is for restructuring the thought, using information provided
by the previous steps. A key process here is to use the assessment data
to remove the cognitive distortion from the thought. For the thought
“I felt uncomfortable at a party, therefore I am socially defective,” the
assessment data may include “my performance as a parent and a
spouse shows that I’m not socially defective,” and the category of dis-
tortion is overgeneralization. The task then is to use the assessment
data to “degeneralize” the thought; for example, “my discomfort at
the party was specific to that situation, and says little about me as a
person.”
“E” stands for execute—that is, act in ways that logically flow from
the restructured thought. In the example of social discomfort at a
party, this step may involve feeling free to act with confidence in
other social domains, and exploring and if necessary remedying the
reasons for discomfort in that one particular social situation.
In context of the theory developed in this book, it is important
to focus the ICARE technique on thoughts and themes involving
burdensomeness and failed belongingness. For example, the identi-
fied thought “I am a burden on my loved ones” could be connected
to the distortion of labeling—putting a global, fixed label on oneself
without considering evidence that would lead to a less negative label.
Assessment data could include the ways that the person contributes
to loved ones, but also more generally, to friends and to society. The
216 ● WHY PEOPLE DIE BY SUICIDE
thought would then be restructured, using the assessment data to
make the label less global and more consistent with objective evi-
dence, such as, “Though I feel a burden on others at times, the truth
is that I contribute in multiple ways.” The last step would involve act-
ing in ways that logically flow from the restructured thought, for ex-
ample, continuing contributing to others and noticing the rewarding
qualities of doing so, and working in concrete ways to minimize feel-
ing a burden and accepting that at times everyone comes up short.
Regarding low belongingness, the identified thought might be,
“I’ll never fit in.” This thought could be connected to the distortion
of catastrophizing—predicting the future in a very negative way,
without consideration of more likely outcomes. Assessment data
could emphasize the relationships and groups in which the person
does experience or has experienced some sense of connection. The
thought would then be restructured using the assessment data to
decastrophize the thought, such as, “Though I may not fit in ev-
erywhere, the truth is that I belong to important relationships and
groups.” The last step would involve acting in ways that logically flow
from the restructured thought, for example, further cultivating those
connections that exist and systematically working to initiate new
connections.
In addition to the ICARE technique, we emphasized some simple
approaches to negative mood regulation—that is, better tolerating
and handling of negative emotions. This is a weak spot for many
people with suicidal symptoms. Consider these examples from indi-
viduals who had attempted suicide: “The situation was unbearable
and I knew I had to do something but I didn’t know what to do”; “I
wanted to get relief from a terrible state of mind.”13 In a relevant
study, researchers assessed therapist ratings of patients’ mood regula-
tion styles. The therapists rated suicidal patients as less likely to en-
gage in active, healthy mood regulation strategies as compared to
nonsuicidal comparison patients.14
Assessment, Intervention, Treatment, and Prevention ● 217
One simple mood regulation technique is the drawing of mood
graphs. These are simple charts, with an x-axis re
presenting the pas-
sage of time and a y-axis representing the intensity of a negative
mood. The task for the patient is to look for a time when negative
moods are intense, and then to sit with a pencil and paper, make a
mood graph, and simply chart the intensity of the mood over time,
once every minute or two, usually for a total of around fifteen to
twenty minutes. This exercise always results in some charted im-
provement in the negative mood. The improvement may not be ex-
treme, but it is visible on the chart nonetheless, and this makes a
powerful point. Specifically, the point is that by simply sitting down
and making a chart and then rating mood periodically, negative
moods lose some of their intensity. Negative moods are not unman-
ageable monsters; they are just unpleasant states that fade with time.
Patients who absorb this lesson become better able to tolerate nega-
tive moods without resorting to extreme solutions like self-injury.
Furthermore, the therapist is then positioned to make another im-
portant point: If the patient is able to gain detectable improvement
just by sitting down and making a simple chart, much more im-
provement can be expected from more thoroughgoing techniques,
like the ICARE approach.
The source of the negative emotion on a mood graph’s y-axis
is likely to consist of either feeling a burden or feeling a lack of
belongingness. If patients chart these feelings over time, they will see
that they lose their edge even over short periods of time. The under-
standing that these feelings, though intensely painful in the present,
will not be permanent and pervasive, steels patients to ride out the
wave of suicidal desire.
The therapeutic approach described thus far has focused on per-
ceived burdensomeness and failed belongingness, because they are
relatively fluid states and thus represent a therapeutic path of least
resistance. The approach works because it systematically corrects and
218 ● WHY PEOPLE DIE BY SUICIDE
amends patients’ views that they are a burden on others and that
they do not belong to valued relationships and groups. However,
because the approach emphasizes mindfulness, planning, and emo-
tional and behavioral regulation, it may also inhibit the expression of
the acquired capability for lethal self-harm and may discourage in-
volvement in provocative experiences that strengthen this acquired
capability. This would occur later in therapy, after self-control is well
established. The therapeutic approach thus prioritizes perceived bur-
densomeness and low belongingness, on the theory that once sui-
cidal desire is decreased, suicidal behavior will be less probable, even
if a patient has acquired the ability for lethal self-injury. Over time,
through repeated practice at things like ICARE and mood regulation,
self-control increases to the point that the acquired ability for self-in-
jury may gradually wane as well.
What about the role of medicines in the management of sui-
cidal behavior? Over the last fifteen years or so, there have been peri-
odic concerns that commonly prescribed antidepressant medicines
like Prozac, Zoloft, Paxil, and their kind actually increase risk for sui-
cidal behavior. Initial concerns that these medicines, called selective
serotonin reuptake inhibitors (SSRIs), were associated with increased
suicidality in adults were put to rest during the 1990s. In 2004, the
concern resurfaced and intensified regarding antidepressants for child-
hood depression. There is some reason for concern. Reviews that
examine both published and unpublished clinical trial data show in-
creased suicidal ideation and behavior in depressed children on anti-
depressants compared to those on placebos, but this is true only for
certain antidepressants like Paxil and Effexor.15
Oddly, it is not true regarding Prozac. Why would some com-
pounds be associated with increased suicidality, when an extremely
similar compound is not? I cannot think of a good answer for this,
with one possible exception. Medicines like Paxil and Effexor have
much shorter half-lives than does Prozac. In this context, half-life
Assessment, Intervention, Treatment, and Prevention ● 219
means the amount of time it takes for half the medicine to clear the
body. Short-half-life medicines clear quickly and thus can shock the
system if not taken very regularly, causing reactions like anxiety, in-
somnia, and agitation, which in turn have been linked to increased
suicidality. If this is the explanation, then it is not the case that anti-
depressants are causing suicidality; rather, it is that some antidepres-
sants need to be carefully managed, because their short half-lives
increase risk for “system shock” and thus for suicidality. In my opin-
ion, the upshot of this should simply be to focus on therapies that
have been repeatedly and clearly shown to be both safe and effective
for childhood depression—specifically, cognitive-behavioral psycho-
therapy and Prozac. From the perspective of my model, I doubt that
antidepressants increase suicidality in children or in anyone. The
majority of the record shows that they improve parameters associ-
ated with my model—things like feeling ineffective and socially iso-
lated.
Prevention efforts too may be informed by the three components
of the current model. As with treatment, the acquired ability to enact
lethal self-injury may not be a wise focus for prevention efforts, be-
cause if someone has this quality, it is relatively static and there is not much to do about it in the short-term. By contrast, efforts that enhance belongingness and efficacy may be protective.
In an intriguing example, researchers studied over 3,000 people
hospitalized because of depression or suicidality.16 Thirty days after
discharge from the hospital, patients were contacted about follow-up
treatment. From those patients who refused follow-up care, a total of
843 patients were randomly divided into two groups. People in one
group received a letter at least four times per year for five years. The
other group received no further contact.
The letters received by the first group were simply brief expres-
sions of concern and reminders that the treatment agency was there
if needed. They were not form letters; the letters received by a given
220 ● WHY PEOPLE DIE BY SUICIDE
individual were always worded differently, and they included re-
sponses to any comments made to previous letters. The researchers
always included a self-addressed, unstamped envelope. They provide
this example of a contact letter: “Dear _______: It has been some
time since you were here at the hospital, and we hope things are go-
ing well for you. If you wish to drop us a note we would be glad to
hear from you.”17
Results showed that patients who received the letter had a lower
suicide rate in the five years after discharge than did patients in the
control group. The researchers specifically attributed this finding to
increased belongingness. Re
ferring to belongingness, they described
it as “a feeling of being joined to something meaningful outside one-
self as a stabilizing force in emotional life . . . it is this force that we postulate as having exerted whatever suicide-prevention influence
the contact program might have generated.” They continued, “[an
earlier paper]18 expressed this concept clearly after recounting sui-
cide prevention measures over 600 years and contemplating what is
really new, observing that ‘there is surely at least one common theme
through the centuries—it is the provision of human contact, the
comfort of another concerned person, often authoritative but maybe
not, conveying a message of hope consonant with the assumptions
and values relevant to that particular time.’”
In the study just described, the prevention technique was targeted
at those previously hospitalized for depression or a suicidal crisis.
How might their success be generalized and presented to the public
at large, or to segments thereof? I am not particularly adept at adver-
tising, public service announcements, and the like, but if I were put
in charge of developing a public service announcement, I think I
might target it to older men—since they are a demographic with
high suicide rates—and its gist might be something along the lines of
“keep your friends and make new ones too—it’s strong medicine.”
This idea reminds me of the man I mentioned in Chapter 4 who, de-
Assessment, Intervention, Treatment, and Prevention ● 221
spite a gruff exterior, called multiple friends each day for years and
years, just to say hello and keep contact. He lived until he was almost
ninety, died peacefully, and his memorial service was standing room
only.
I noted earlier that the acquired ability to enact lethal self-injury
may not be a useful target for prevention efforts, because this quality
is relatively static and not very malleable, at least not over the short-
term. But this ability is important to consider in planning preven-
tions, because efforts that unintentionally foster habituation to sui-
cidal stimuli may backfire. For example, I would not recommend a
“scare tactic” intervention in which graphic pictures of those who
died by suicide are shown, because this has the potential to further
habituate at-risk people to the idea of death by suicide.
Why People Die By Suicide Page 28